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The Centers for Medicare & Medicaid Services is partway through a nationwide initiative to replace the patchwork system of Medicare carriers and fiscal intermediaries with a Medicare administrative contractor system divided into 15 distinct jurisdictions. When the effort is complete by 2011, all physicians and hospitals in a given jurisdiction will have one MAC that has won a contract to handle all their Part A and Part B claims.
For many physicians, this means going from a carrier they may have been billing for decades to a new, unfamiliar MAC with no prior dealings in the state. Some doctors who made the switch report that the new contractors are not up to the task.
Leslie G. Bennett, MD, an internist in Queens, N.Y., suddenly stopped receiving Medicare checks in late June just as National Government Services was taking over from long-time local carrier Group Health Inc. NGS, the new MAC for New York and Connecticut, said it was working to resolve a backlog of claims, but Dr. Bennett's payments did not start flowing again until late September. By then, the months of missed Medicare checks had taken their toll.
"We've maxed out all our credit lines, we've got payroll taxes coming up, we've got malpractice insurance payments coming up, we've got suppliers screaming bloody murder," he said. "I don't know how the hell I'm going to pay it all."
24 states have switched from old Medicare carriers to their new MACs.Joseph J. Tartaglia, MD, a cardiologist in White Plains, N.Y., also saw his Medicare payments dry up earlier this year after a problem arose related to his Medicare enrollment. Dealing with the MAC's customer service so far has gotten him nowhere. The payment delays also have forced him to take out loans and secure a large credit line. "It's very frightening when your practice is almost 50% Medicare and it's not paying," he said.
NGS did not anticipate that so many doctors in the state would still be filing paper Medicare claims, and most of the payment problems are occurring in that process, said Michael Davis, the MAC's manager of provider outreach and education. Although the situation can be unpleasant for those with cash-flow issues, both the physicians and the contractor will be able to tackle the learning curve and get past the initial bumps that come along with any major transition, he said.
New York is not the only state dealing with these problems. Thousands of California physicians, for example, have reported payment stoppages to Palmetto GBA, the new MAC that took over Medicare claims processing for that state and two others in September. That situation became so bad that Palmetto had to start training more personnel quickly to handle an explosion in call volume.
Physician complaints from some of the roughly two dozen states that already switched from their old carriers to their new MACs are following a common theme. Because CMS chose the contractors in part based on competitive bids, many fear that winning MACs have more limited resources and therefore are overwhelmed by the sudden influx of claims, unable to help physicians prepare for the change and slow to address problems.
"Injecting competition into the MAC program has had the unintended consequence of creating a race to the bottom as contractors attempt to underbid each other and thus are awarded contracts that do not include an appropriate level of physician outreach and result in a diminished level of customer service," said American Medical Association Board of Trustees Chair Joseph M. Heyman, MD.
CMS has named new Medicare contractors for 9 MAC jurisdictions; 6 more must be chosen.Arthur D. Snow Jr., MD, a family physician in Shawnee Mission, Kan., saw this firsthand after Wisconsin Physicians Service Insurance Corp. took over operations from longtime carrier BlueCross BlueShield of Kansas. Dr. Snow's Medicare payments, which make up nearly all of his income, did not stop outright. Instead, they slowed down significantly to the point where he needed to secure loans to keep afloat. Only after months of inquiries did he ascertain that the new contractor was using different guidelines to process paper claims.
WPS encountered some claims issues that needed fixing, but those affected only a small number of doctors, said Guy Ringle, the MAC's senior vice president of Medicare operations. During the months when the contractor was resolving the problems, it was able to keep overall payment flow consistent with past levels.
But by saving costs through forgoing a Kansas-based medical director and regular educational sessions with local physicians, the company is relying on reaching out from its Wisconsin headquarters via Web-based bulletins. Most doctors, though, are too busy to track these, Dr. Snow said. The AMA has called on CMS to mandate that contractors install at least one medical director per state instead of the current requirement of at least one per MAC jurisdiction, which can span as many as six states.
Some MACs are being blamed for issues that are not necessarily related to Medicare contracting reform. For instance, some payment stoppages occurred because of the final switchover in late May to the National Provider Identifier system, which coincided in some cases with the transition to the new contractors.
NPI-related payment problems in California are largely behind the thousands of complaints that have swamped Palmetto GBA's phone lines since it took over, said Mike Barlow, the Palmetto vice president heading up the transition. But many of those issues date back as far as May, meaning that the state's previous carrier and the physicians did not resolve them in the intervening months. Now Palmetto has inherited the problems -- and the heightened physician emotions that go along with them, he said.
The California situation prompted CMS to revisit the contract and work with Palmetto to beef up customer service, said Karen Jackson, the Medicare contractor management group's director. Still, the transition in other states in the nine jurisdictions with new MACs has been largely uneventful, she said. The agency is forging ahead with plans to name winning bids for the six remaining jurisdictions by the end of the year.
Contrary to public perception, CMS does not always pick the lowest bidder when it chooses a carrier's replacement, Jackson said. The agency completes a rigorous technical evaluation and "cost realism" process to ensure that a bidder can deliver on what it promises. "We have a high level of confidence that we are not racing to the bottom," she said.
CMS continues to work individually with doctors on payment problems. Jackson said a physician first should try to resolve issues with his or her new MAC and then call the CMS regional office if the attempt is unsuccessful. In some cases, MACs might be able to approve advance Medicare payments if the physician demonstrates a major cash-flow problem.
Premiums for workers increased on average by 5% this year, a growth rate 1.1% slower than seen in 2007, according to an annual employer benefit survey released Sept. 24 by the Kaiser Family Foundation and Health Research & Educational Trust, a health care research organization. But this relatively modest growth was offset by a move toward increased employee cost-sharing and more limited benefits, according to the study's authors.
"There is not one story, but there are several different stories here," said Drew Altman, PhD, president and CEO of the Kaiser Family Foundation.
The average annual cost of a family plan in 2008 was $12,680, or $574 more than last year. Annual single coverage cost $4,704, an increase of $225. The survey was based on interviews with nearly 2,000 firms conducted from January to May.
The faltering economy, a lack of new blockbuster drugs and increased cost-shifting to employees helped slow premium growth, the report found. For example, 18% of all covered workers in 2008 enrolled in a plan with a deductible of $1,000 or more, up from 12% in 2007. Thirty-five percent of employees at small businesses -- those with three to 199 workers -- were responsible for paying the first $1,000 of their health care costs, up from 21% in 2007.
Average health plan premium costs nearly doubled from 1999 to 2008.Employer-sponsored plans also were increasingly likely to have different deductibles, co-pays and spending cap arrangements today than they did several years ago.
Costs can vary if a patient goes out of network for hospital coverage or sees a specialist instead of a primary care physician, said Gary Claxton, director of the Kaiser Family Foundation's Health Care Marketplace Project. "It's much harder now to get a grasp of what these plans are through a survey."
Claxton expects increased employee cost-sharing to continue, in part because the slow economy puts workers in a tough bargaining position.
Altman also expects premiums to increase more quickly in the future. "There's no evidence that we've done much, if anything, to deal with the fundamental underlying drivers behind the rates of increase we have in health care costs."
An annual survey of health plans released Sept. 22 by Hewitt Associates, a human resources consultant, predicts a 6.4% average increase in health care costs in 2009. Its estimates are based on a cost and performance analysis database of more than 1,800 health plans throughout the U.S.
Karen Ignagni, president and CEO of America's Health Insurance Plans, said her association has a strategy for further controlling premium hikes. AHIP supports providing patients and their doctors with more information about the cost-effectiveness of drugs, treatments and medical technology; expanding wellness, disease management and care coordination; and investing in health information technology to reduce medical errors and improve efficiency.
A recent poll shows that voters are still worried about health care costs, Altman said, likely in part because average health plan premiums more than doubled between 1999 and 2008. Twenty-four percent of more than 1,500 adults in the August Kaiser Family Foundation Health Tracking Poll said they had a serious problem paying for health care coverage.
Larger employers were more likely to offer high-deductible health plans this year, but small business employees were more likely to enroll in them, the Kaiser/HRET survey found.
Overall, 8% of covered employees enrolled in high-deductible health plans this year, up from 5% in 2007. These were plans with a deductible of at least $1,000 for single coverage and $2,000 for family coverage. Plans designated as HDHPs also must offer the option of establishing health savings or reimbursement accounts.
Nearly 90% of large employers offer worker wellness programs.HDHPs offer less expensive premiums than the other major plan types: $10,121, on average, for family coverage in 2008. But proponents and detractors fiercely debate the plans' overall effects on health spending and the health of their enrollees.
Large employers -- those with 200 or more workers -- were more likely than smaller firms to offer wellness programs, the Kaiser/HRET report found. Nearly 90% of large businesses' health plans -- but just more than half of small firms' plans -- offered programs such as weight loss assistance, smoking cessation or nutrition classes.
Large employers are confident that wellness programs can reduce health care spending, but research has not yet confirmed that view.
"The peer-reviewed literature would not be so optimistic and upbeat about these programs improving health and particularly reducing costs," said Jon Gabel, senior fellow at the National Opinion Research Center.
But many wellness programs are new, and employers believe they will bear fruit over time, said the Kaiser Family Foundation's Claxton.
Baucus, speaking Sept. 23 at a U.S. News & World Report forum on the uninsured, said he plans to outline his measure later this year. The Senate Finance Committee -- a key stop for most health care legislation -- has held a series of hearings on health system reform in recent weeks to lay the groundwork for a major bill.
"This is going to be one of my top issues -- one of my very top issues -- next year," he said.
The measure will be based on a few major principles: Universal coverage, incentives for preventive care and wellness programs, and the concept of sharing the burden of health system reform.
Normally, bill backers require 60 Senate votes to end debate, but Baucus said he would consider using the process known as budget reconciliation to adopt the health care bill with a simple majority vote and limited amendments. That tactic has been used to pass several major measures in recent years, including the 2001 and 2003 tax cuts. Baucus could prevail if Democrats maintain control of the Senate next year.
Health system reform is one of the top 3 issues voters want addressed.The senator is starting out with a bipartisan approach. If lawmakers find common solutions for tackling the uninsured problem, for improving quality and for lowering costs, they might end up with widely supported legislation, he said. For example, paying physicians for aspects of patient care that are not currently compensated could persuade doctors to accept larger health system reform.
American Medical Association President Nancy H. Nielsen, MD, PhD, who introduced the forum's panelists, said policymakers need to do more than debate why the country has nearly 46 million uninsured people. "We must not just focus on the problem, but focus on getting to a solution," she said.
Many health care stakeholders are more motivated to reform the health system now than in previous decades because health care spending increases have outpaced inflation in recent years, said panelist Paul H. Keckley, PhD, executive director of the Deloitte Center for Health Solutions, a policy analysis group.
Baucus said many people might not be enthusiastic about the health system, but they do understand it. "So I think a lot of Americans want improvements, but they are concerned about changes that might disrupt what they currently have."
Health system reform is one of the top three issues voters want Congress and the White House to address, said panelist Mary R. Grealy, president of the Healthcare Leadership Council, a coalition of health care industry CEOs. "But we have to be very careful. It actually is working well for the vast majority of people. And if you threaten the coverage that they have, they don't like that threat of dislocation," she said.
But Baucus said many people might not realize how steady increases in health care spending threaten the economy. If left unchanged, health spending will grow to take up nearly half of the country's gross domestic product by 2082, according to the Congressional Budget Office.
"The problem is much worse than most Americans really know, because if this current trend continues, we are going to be in a very deep, deep hole that is going to be harder and harder for us to dig out of," he said.